ST CROIX FALLS, WI - Federal inspectors documented significant infection prevention and vaccination program deficiencies at Divine Rehabilitation and Nursing At St Croix during a July 2024 survey, finding systematic failures in resident immunization protocols and infection control specialist training.
Infection Prevention Specialist Lacks Required Training
The facility received a citation for failing to ensure their infection prevention specialist possessed the specialized training required by federal regulations. This violation represents a fundamental breakdown in the facility's ability to protect residents from healthcare-associated infections and implement evidence-based infection control practices.
Infection prevention specialists serve as the cornerstone of nursing home safety programs, responsible for developing protocols that prevent the spread of infectious diseases among vulnerable elderly populations. These professionals must undergo specific training in epidemiology, microbiology, and infection control practices to effectively identify risks and implement protective measures.
The absence of proper training for this critical position compromises the facility's entire infection prevention program. Without specialized knowledge, the infection prevention specialist cannot adequately assess infection risks, develop appropriate isolation procedures, or ensure staff follow proper hand hygiene and personal protective equipment protocols.
Comprehensive Vaccination Program Failures
Inspectors found the facility lacked a comprehensive system for ensuring residents received influenza and pneumococcal immunizations, affecting 9 of 13 sampled residents. The violations demonstrate systematic failures in the facility's vaccination program across multiple vaccine types.
Influenza Vaccination Deficiencies: The CDC recommends annual influenza vaccination for all adults, particularly important for elderly nursing home residents who face higher risks of severe complications from flu infections. The facility failed to properly offer, educate, or document influenza vaccination status for multiple residents.
Pneumococcal Immunization Gaps: Pneumococcal vaccines protect against serious infections including pneumonia, meningitis, and bloodstream infections. The CDC guidelines require specific timing for pneumococcal vaccines, with PCV13 administered at least one year after the most recent pneumococcal vaccine, followed by PPSV23 at least 8 weeks later.
The facility's vaccination program showed multiple deficiencies across resident cases. For newly admitted residents, staff failed to assess immunization status, offer recommended vaccines, or provide proper education about vaccination benefits and risks. Even when consent forms were present, they lacked proper screening questions and education documentation required for safe vaccine administration.
COVID-19 Vaccination Program Breakdown
The facility also failed to properly implement COVID-19 vaccination protocols for 8 of 13 sampled residents. Current CDC guidelines recommend COVID-19 booster vaccinations every six months for adults, with more frequent boosters for immunocompromised individuals.
One resident interviewed by surveyors confirmed the systematic nature of these failures, stating "no one has spoken to [me] about vaccinations" and that they were not offered influenza, pneumococcal, or COVID-19 vaccines during admission.
Staff Acknowledgment of Systemic Issues
During interviews with federal surveyors, facility leadership acknowledged the widespread nature of these problems. The Director of Nursing and Registered Nurse staff admitted that "the process for following up with vaccinations after residents are admitted is a working process at this time."
Staff specifically acknowledged that "the facility has recognized the process for updating immunizations, offering, and educating on vaccinations was not being completed throughout the whole facility." One nurse stated that vaccination protocols "had fallen through the cracks."
Medical Significance of Vaccination Failures
Vaccination programs in nursing homes serve as critical protective measures for residents who face elevated risks from infectious diseases due to age-related immune system changes and underlying health conditions. Influenza infections can lead to pneumonia, hospitalization, and death among elderly populations.
Pneumococcal infections pose particular dangers for nursing home residents, potentially causing severe pneumonia, bloodstream infections, and meningitis. These infections carry high mortality rates among elderly individuals and can spread rapidly in congregate care settings.
COVID-19 continues to present significant risks for nursing home populations, with older adults experiencing higher rates of severe illness, hospitalization, and death. Regular booster vaccinations help maintain protective immunity levels as vaccine effectiveness wanes over time.
Industry Standards and Best Practices
Federal regulations require nursing homes to maintain comprehensive vaccination programs that include proper assessment, education, administration, and documentation. Facilities must ensure residents receive age-appropriate vaccines unless medically contraindicated or declined after proper education.
Effective vaccination programs should include systematic processes for assessing immunization status upon admission, providing evidence-based education about vaccine benefits and risks, offering recommended immunizations, and maintaining accurate documentation of vaccination status and any declinations.
The facility's consent forms lacked essential elements including proper screening questions to ensure safe vaccine administration and documentation that education was provided. These components are necessary to protect residents from adverse reactions and ensure informed decision-making.
Regulatory Response and Consequences
The violations carry "minimal harm or potential for actual harm" designations, indicating that while no immediate serious injuries occurred, the deficiencies created risk for adverse outcomes. The facility must submit a plan of correction addressing how it will remedy these systematic failures.
The inspection findings highlight the importance of robust infection prevention and vaccination programs in protecting vulnerable nursing home populations. Facilities must maintain properly trained infection prevention specialists and implement comprehensive systems to ensure residents receive recommended immunizations according to current medical guidelines.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Divine Rehabilitation and Nursing At St Croix from 2024-07-17 including all violations, facility responses, and corrective action plans.
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